Healthcare Provider Details

I. General information

NPI: 1760751267
Provider Name (Legal Business Name): JANE ELIZABETH NEE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 S 102ND ST STE 340
MILWAUKEE WI
53227-2147
US

IV. Provider business mailing address

2448 S 102ND ST SUITE 340
MILWAUKEE WI
53227-2466
US

V. Phone/Fax

Practice location:
  • Phone: 800-776-7016
  • Fax:
Mailing address:
  • Phone: 800-776-7016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1109-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: